A study from Melbourne, Australia has found that acupuncture can significantly reduce the symptoms of persistent allergic rhinitis (PAR), a.k.a. hay fever. This was a randomized, single-blind, sham-controlled trial included 80 patients with PAR aged 16-70 years, who were randomly assigned to real or sham acupuncture. Three key acupuncture points, Yingxiang L.I.-20, Yintang M-HN-3 and Fengchi GB-20, plus one supplementary point (determined individually on the basis of traditional Chinese Medicine pattern differentiation) were used for each participant. After a one-week baseline period, participants were treated twice weekly for eight weeks and followed up for another 12 weeks. Nasal obstruction, sneezing, rhinorrhea and nasal itch were each self-assessed daily on a 5-point scale, and individual symptom scores were added to give a sum of the symptom scores: total nasal symptom score (TNSS). A secondary outcome was use of PAR relief medication. At the end of eight weeks’ treatment, the weekly mean difference in TNSS from baseline was significantly greater with real (-17.2) than with sham acupuncture (-4.2) and these benefits persisted three months after the end of treatment. Comparisons of relief medication scores revealed a significant decline in the use of medication in the real acupuncture group between baseline and Week 8 of treatment, the reduction being still apparent at the end of follow-up.

This research is convincing. The effect size is not enormous, and we do not know how long the effect will last, but it does suggest another approach for people who have chronic symptoms and for whom medications are ineffective, or who do not want to take medications, or have side effects from them.

It may be relevant that some years ago it was shown that needling the Fengchi point - which lies at the base of the skull at the back of the head - increases some components of cerebral blood flow. That may give us a mechanism of action of the acupuncture in this trial.

“I am pretty sure that, if you will be quite honest, you will admit that a good rousing sneeze, one that tears open your collar and throws your hair into your eyes, is really one of life’s sensational pleasures.”
–Robert Charles Benchley (American Humorist, Critic and Parodist, 1889-1945)

“The nose is for breathing, the mouth is for eating.”
–English Proverb

“Warmth, moisture, food-these are the causes that activate latent germs and arouse them to activity. They exist, all except the food, in the mouth, nose and throat at all times. The food is thrown out into these, as excretions, in disease. The germs feed on the excretions. They are scavengers. They were never anything else and will never be anything else. They break up and consume the discharge from the tissues. This is the function ascribed to germs everywhere in nature outside the body and is their real and only function in disease. They are purifying and beneficial agents. The medical profession has worked itself into hysteria over the germ theory and is using it to exploit an all too credulous public. Germs are ubiquitous. They are in the air we breathe, the food we eat, the water we drink. We cannot escape them. We can destroy them only to a limited extent. It is folly to attempt to escape disease by attempting to destroy or escape germs. Once they are in the body, the physician has no means of destroying them that will not, at the same time, destroy the patient. We cannot avoid germs. We must be proof against them. We have to accept them as one of the joys of life.”
–Herbert Shelton (English Evolutionary Philosopher, 1820-1903)

You can find some articles on Attention-Deficit/Hyperactivity Disorder (ADHD) here, and also some of the evidence that ADHD is a “real” illness and not just a label for socially unacceptable behavior. That being said, it is essential to take extra care when making the diagnosis. Mud sticks, and diagnostic mud sticks like glue. It can be hard to “unmake” a diagnosis.

As with any problem, the most effective way of helping it is to address the physical, psychological, social, subtle and spiritual aspects of the situation.

Medicines can definitely have a place in the management of ADHD, and the reason for treating ADHD is not so that people get better grades in school or do better at their jobs. It is to prevent the long term problems that may follow from inadequately treated ADHD.

There is a large and growing body of research on non-pharmacological approaches to treating ADHD. A literature search has turned up over two hundred papers, over half of which report some empirical research. Some of the research is summarized in a short paper aimed at health care professionals.

Research has shown that more than 50% of American families who receive care for ADHD in specialty clinics also use complementary or alternative medical (CAM) therapies, if you include things like modifying their diet or other aspects of their lifestyle. Despite that, only about 12% of families report their use of CAM to their clinician. Despite that low rate of families reporting the use of unorthodox therapies, a national survey of pediatricians showed that 92% of them had been asked by parents about complementary therapies for ADHD. The trouble is that many pediatricians have not been taught very much about the pros and cons of these approaches.

The most commonly used CAM therapies for ADHD are dietary changes (76%) and dietary supplements (> 59%). I have talked about food additives and one type of diet in the past. Now let’s look in a little more detail.

The 3 main dietary therapies for ADHD are:

• The Feingold diet,
• Sugar restriction, and
• Avoiding suspected allergens.

Sometimes these diets are used in combination.

The Feingold Diet
The Feingold diet is the most well known dietary intervention for ADHD. It aims to eliminate 3 groups of synthetic food additives and 1 class of synthetic sweeteners:
Synthetic colors (petroleum-based certified FD&C and D&C colors);
Synthetic flavors;
BHA, BHT and TBHQ ; and
The artificial sweeteners Aspartame, Neotame, and Alitame.

Some artificial colorings such as titanium dioxide are allowed.

During the initial weeks of the Feingold program, foods containing salicylates (such as apples, almonds, and grapes) are removed and are later reintroduced one at a time so that the child can be tested for tolerance. Most of the problematic salicylate-rich foods are common temperate-zone fruits, as well as a few vegetables, spices, and one tree nut.

During phase 1 of the Feingold diet, foods like pears, cashews, and bananas are used instead of salicylate-containing fruits. These foods are slowly reintroduced into the diet as tolerated by the child.

The effectiveness of this diet is controversial. In an open trial from Australia, 40 out of 55 children with ADHD had significant improvements in behavior after a 6-week trial of the Feingold. 26 of the children – 47.3% - remained improved following liberalization of the diet over a period of 3-6 months.

In another study, 19 out of 26 of children responded favorably to an elimination diet. What is particularly interesting is that when the children were gradually put back on to a regular diet, all 19 of them reacted to many foods, dyes, and/or preservatives.

In yet another study, this one a double-blind, placebo-controlled food challenge in 16 children, there was a significant improvement on placebo days compared with days on which children were given possible problem foods. Children with allergies had better responses than children who had no allergies.

Despite this research many pediatricians, particularly in the United States, do not believe the evidence regarding the effectiveness of elimination diets or additive-free diets warrants this challenging therapy for most children.

There is an interesting difference in Europe. In 2004 a large randomized, blinded, cross-over trial of over 1800 three-year-old children was published. The results showed consistent, significant improvements in the children’s hyperactive behavior when they were on a diet free of benzoate-preservatives and artificial flavors. They had worsening behavior during the weeks when these items were reintroduced. On the basis of this and other studies, in 2004 schools in Wales banned foods containing additives from school lunches. It has been claimed that since the ban, there has been an improvement in the afternoon behavior of students.

The biggest problem with the Feingold and other elimination diets is that they are hard to follow and to maintain. But for some children and families, the inconvenience and stricter attention to food have worthwhile results.

It is also essential to ensure that children on any kind of diet maintain adequate nutrition: there have been many examples of that simple rule not being followed.

Sugar Restriction
The notion that sugar can make children “hyper” entered the mainstream over twenty years ago, and is now on the list of things that “everyone knows.” But happily it is not true. At least 12 double-blind studies have failed to show that sugar causes hyperactive behavior. Some researchers suggest that sugar or ingestion of high-carbohydrate “comfort foods” is actually calming, and that children who seek these foods may be attempting to “self-medicate.”

There are plenty of very good reasons for children to avoid candy, but hyperactivity is not one of them.

Food Allergies
There is clear evidence that children, and perhaps adults with ADHD are more likely to have allergies. That lead to the obvious question whether children with ADHD allergic or sensitive to certain foods. (It is useful to differentiate “allergies” that are the result of abnormal reactivity of the immune system to proteins in food, from “sensitivities” that are the direct result of substances in food: the two have different treatments.)

It is certainly true that food allergies and food sensitivities can generate a wide range of biological and behavioral effects. Gluten sensitivity (celiac disease) is known to be linked to an increased risk of ADHD and other symptoms.

In an open study of 78 children with ADHD referred to a nutrition clinic, 59 improved on a few foods trial that eliminated foods to which children are commonly sensitive. For the 19 children in this study who were able to participate in a double-blind cross-over trial of the suspected food, there was a significant effect for the provoking foods to worsen ratings of behavior and to impair psychological test performance.

For more than 30 years one of the tests used to track allergies has been the radioallergosorbent test (RAST). It is not much used these days since technology has moved on. In an allergy testing study of 43 food extracts 52% of 90 children with ADHD had an allergy to one or more of the foods tested. Over the next few years several researchers carried out open-label studies in which children with ADHD and food allergies were treated with a medicine called sodium cromoglycate, that prevents the release of inflammatory chemicals such as histamine from mast cells. Some of the reports suggested that it could help in some children.

Other popular dietary interventions include eating a low glycemic index diet to avoid large swings in blood sugar. Another strategy has been to “go organic” to reduce the burden of pesticides, hormones, antibiotics, and synthetic chemicals in the child’s system. These diets need more scientific study but they are probably safe if expensive.

There are plenty of practitioners and commercial entities who claim to be able to identify food sensitivities with all kinds of methods from blood and muscle testing to electrical and energetic techniques. Some may be helpful, but few have been proven to be effective.

What Should Parents do About Diet, Nutrition, Allergies and Sensitivities?
It is very difficult to predict whether an individual child will be helped by changes in diet. However, as long as the child’s needs for essential nutrients are met these diets should be safe.

It is an extremely good idea for parents to keep a diet diary for one to two weeks to see if anything obvious jumps out. Then trying an additive-free diet, low in sugar and avoiding foods that are suspected of exacerbating symptoms. You will normally find the answer - yes or no - within a few weeks.

What is the Evidence for Food Sensitivities and ADHD in Adults?
Not a lot!

There are plenty of people who have reported that dietary restrictions have helped them, but there is very little evidence. One of the problems about looking for food sensitivities is that there is a high placebo response rate. But if you have adult ADHD, it may be worth investigating. Just make sure that any diet that you use is nutritionally sound. And if you don’t find anything reconsider another approach.

After a couple of weeks away I was distressed to see that I was going to be returning to a city which has just been rated as the most challenging place in America for people with asthma.

This is the list according to the Asthma and Allergy Foundation of America:

1. Atlanta
2. Philadelphia
3. Raleigh, North Carolina
4. Knoxville, Tennessee
5. Harrisburg, Pennsylvania
6. Grand Rapids, Michigan
7. Milwaukee
8. Greensboro, North Carolina
9. Scranton, Pennsylvania
10. Little Rock, Arkansas

I am pleased to say that I do not have asthma, though I have a strong family history of it. If you live in one of these cities, or any other with a high rate of pollution, there is nothing much to be done apart from:

Staying indoors when the weather is bad

Using an air purifier

Keep to a diet designed to reduce your risk of inflammation

Use homeopathy and tapping therapies to help when necessary.

And sadly, for some people, medicines are the only option. But I always try the other approaches as well.

I first learned to do hypnosis in 1980, and I have always found it a useful adjunctive treatment for some people, though in recent years I have spent far more tie teaching people to use self-hypnosis.

The research data on hypnosis has also been growing, to the extent that nearly two years ago an article in the Mayo Clinic Proceedings, a fairly conservative journal, suggested that the time had come for an expanded role for hypnosis in general medicine as well as a study of different techniques that are in use.

Hypnosis and self-hypnosis may affect an illness directly, or it might reduce a trigger to the illness, say if anxiety triggers an asthma attack, we could use hypnotherapy to treat the anxiety. Hypnosis may improve a person’s subjective responses to the illness. It might also be useful to help counteract side effects in people who just have to be treated with conventional medications.

Many case reports of apparent cures with hypnosis have found their way into the popular press.  I have mentioned that over a period of five years I spent one to two days a week going through and checking most of these reports in all the languages that I can read. Sadly some of them turned out not to hold much water.

But now the quality of the research has improved enormously. I have been particularly impressed with some of the studies on allergy: it is very remrakable to think that we can make specific suggestions that produce demonstrable effects on the immune system. I particularly liked a study from Switzerland that was published in the journal Psychotherapy and Psychosomatics.

A team from Basel University taught 66 people with hay fever how to do self-hypnosis and found that it helped them to alleviate symptoms such as runny nose.

The volunteers also took their regular hay fever medicines, but the effect of hypnosis appeared to be additive so that they could reduce the doses that they needed to take.

The study took place over two years and included two hay fever seasons. During the first year, one group of the volunteers with hay fever were taught and asked to regularly practice hypnosis as well as take their usual allergy medicine. The training consisted of one two-hour session with an experienced trainer. The remaining volunteers had no other treatment apart from their normal allergy medication.

After a year, the researchers found the volunteers who had been using self-hypnosis had reported fewer symptoms related to hay-fever than their fellow volunteers.

During the second year, the researchers taught the remaining "untrained" volunteers how to use hypnosis. By the end of this year, these volunteers also reported improvement in their hay-fever symptoms.

Although the improvement in symptoms was not statistically significant the researchers also found that the volunteers had cut down on the amount of hay fever medication they used after learning self-hypnosis.

There is another interesting piece of research on this topic. You will probably have experienced a histamine reaction: the typical wheal, flare and swelling that can occur after, say, an insect bite. Researchers form Denmark used hypnosis to induce emotions of sadness, anger, and happiness, to see whether these emotions would have any effect on the skin’s response to histamine. Not only did mood have an effect on the skin reactions, but also people who were more susceptible to hypnosis were more reactive to histamine.

Hypnosis is being used with many clinical conditions, from asthma to migraine and irritable bowel syndrome. It is not a panacea, but it can be a very useful tool. And it tells us a lot about the power of the mind to influence virtually every system of the body.

Few things generate as much heat and as little light as the debate about a possible association between food additives and cognition, mood and behavior.

There are a number of ways in which food may influence all three, including:

1. Malnutrition
2. Composition of the diet
3. Nutrient quality of the diet
4. Eating habits
5. Pharmacological effects of foods
6. Food allergy
7. Food sensitivity
8. Contamination of food with heavy metals, hormones and pesticides
9. Fatty acid deficiency
10. Food additives

It is often surprising to learn that many people do not realize that in children – particularly if malnourished – omitting breakfast can have a marked effect on cognitive functioning. But it is the last of those that I want to look at today.

Until the 1950s if food manufacturers wanted to add color to a food it was done primarily with natural plant and vegetable based compounds: pale red colors could be achieved from beets; green from chlorophyll-containing vegetables; yellows and orange could be achieved from extracts from a number of other plants and spices. But then things began rapidly to change as we outlined in Healing, Meaning and Purpose.

The notion that food additives could be a cause of hyperactivity is at least 30 years old. I think that Ben Feingold was the first to introduce the idea and with it his notoriously difficult diet.

Over the years there have been some positive clinical trials of the diet and some negative. But I think that every clinician working with behavior problems has seen some startling improvements in some children and adolescents when they go on an elimination diet.

In 1985 a controversial study published in the Lancet claimed to show that 79% of hyperactive children had symptomatic improvement when food chemicals were removed from their diet. Then when the food chemicals were re-introduced the symptoms returned. No other study has ever produced figures anything like that high.

It is also important that in young children, though additives may cause a problem in some, there does not seem to be a link between allergies and food sensitivities, and parents often pick up behavior changes that simple clinical screening tools do not. So mom and dad may really know best.

Several years ago we tried to look at the impact of food additive not on behavior, but on headache. When the additives were administered double blind, we were unable to replicate most people’s symptoms, even when they were sure that a certain food caused a problem.

However, unsupervised restriction diets are not without their dangers. And we also need to make sure that practitioners know what they are doing: I once saw a young woman who had seen by an “alternative allergist,” who had left her on a diet consisting of spring water, rice and lettuce. And nothing else.

Another problem is that many of us do not know what additives are lurking in the food that we eat. There was a recent study in the United Kingdom indicated that on average, Britons consume 20 different food additives every day, with some eating up to 50. Yet most people were unaware of this figure, with nearly half of the 1,006 people surveyed thinking they ate only 10 additives each day.
The research also found that many people did not understand which foods are most likely to contain additives. I have not yet seen the raw data from this study, but I shall have more to say about it once it becomes available.

A number of large independent studies are currently underway (for example, here) which should help us to better identify who is susceptible to additives, how to test for sensitivity to additives and who might benefit from their withdrawal.

The trouble with a lot of the discussion about food additives, behavior, mood and cognition is that it usually begins from a false premise: that there is a single cause for a behavior.

When I am teaching it continues to astonish me that most health care professionals still expect there to be one “cause” for a problem. Yet as I have mentioned before, this is rarely clinical reality.

A food additive may be associated with problems, but only in a minority of children, and only if they are genetically predisposed and if the right set of environmental circumstances are in place.

If you suspect a problem, first, learn to look at labels. And see if simple exclusion helps. An allergist is the next stop, but also ask whether an additive could be causing a biochemical rather than an allergic problem. If it is a biochemical effect, it may not show up on routine allergy tests, but there are other ways of testing.